Orthopaedics is the surgical specialty that deals with the bones, joints and muscles, and sometimes the nerves. However, most children do not need surgery; they usually just need a thorough assessment and a full explanation. This website provides information on common conditions and on how to find advice and help. Some children will benefit from the expertise of other medical or non-medical professionals such as physiotherapists.
1 Are orthotics of proven benefit for flat feet in children?
The short answer is no. The long answer is that the first thing to establish is whether the feet are flexible or stiff. A stiff and painful flat foot must be assessed for the underlying cause. Once this is established the foot might be helped by a carefully made orthosis; ie made by an orthotist. There is no point attempting to correct a stiff foot with an orthosis, but changes in biomechanics, particularly the ground reaction through the foot can be enough to relieve symptoms. A soft accommodating shoe, such as a trainer, is often the best tolerated solution and can come as a relief to a child who has been sentenced to months of “insoles” and other devises. Occasionally surgery is needed, depending on the cause. Orthoses are of no benefit for flexible flat feet, which are a normal variant. Several studies have shown that whether or not a medial longitudinal arch develops with age is not changed by any intervention such as exercises or orthoses.
Ref: Wenger et at J Bone Joint Surg 1989;71A:800-810
2 When should we be concerned that knock-knees and bow legs are potentially pathological? What investigations should we do and when should we refer?
All babies are born with bow legs. The vast majority of children over 3years do not have bow legs; exceptions require referral. As bow legs resolve and knock knee develops, the latter will normally increase only for a year or so. There are no common causes of persistent or progressive deformity but they range from Blount’s disease to skeletal dysplasias. The rule of thumb is to check for asymmetry and worsening, and to remember the natural history of coronal alignment (fig.). Rickets is relative common but is not always nutrition or sunlight related and requires paediatric assessment.
3 Are overriding toes of clinical significance?
The overriding 5th toe is generally present from birth and is a permanent feature. It tends to rub in the toe box and if so needs surgery preferably before school age; some respond to maternal massage however if started early. Curly toes on the other hand are much less frequently symptomatic; for example the pressure from the sole of the shoe can cause the tips of the toes to develop callosities and the nails can curl over. The nail can dig into the adjacent toe. The nails are often tucked underneath leading to cosmetic concerns, especially with nail varnish. If left, most will resolve by school age and of those that don’t most will remain asymptomatic. If symptomatic, they are best treated before the age of 10, although adults and teenagers can have treatment too. Many parents will ask for treatment before symptoms occur if the curly toes look severe. The overriding second toe is also rarely symptomatic, unless crammed into a shoe; the occasional fixed deformity responds to extensor tendon release. Sometimes an x-ray is needed to look for other causes.
4 What are the differentiating factors between an irritable hip and, for example, SUFE or Perthes’ disease?
When a child is limping, the most important diagnosis to exclude is infection. A child that cannot bear weight has an infection, a fracture or SCFE until proven otherwise. If a child is well, can weight-bear and has a full range of movement on formal examination, an infection is unlikely. Perthes’ and SCFE are also unlikely. Of these two, it is SCFE that is the more urgent. This will be a teenager with groin adductor or buttock pain after minor or no trauma and a reduced range of movement, typically flexion and internal rotation; an x-ray is needed, including frog laterals, to exclude the diagnosis. Perthes’ causes anxiety and for this reason an outpatient appointment is needed as soon as possible, but it is not an emergency. An irritable hip (also called transient synovitis) is a diagnosis of exclusion and can often only be made after x-rays, CRP, ESR and an ultrasound. Children will limp for other reasons too, from discitis to calacnealapophysitis and sarcomas to appendicitis. Therefore careful and repeated clinical assessment is as usual the key to diagnosis.
Ref: Factors Distinguishing Septic Arthritis from Transient Synovitis of the Hip in Children. Caird MS et al. J Bone Joint Surg 2006;88A: 1251-1257.
5 How accurate are the standard screening tests for congenital dislocation of the hip? Health visitors often worry about asymmetrical skin creases – how relevant are these?
We tend to use the term developmental dysplasia of the hip (DDH) or primary dysplasia of the hip, rather than congenital dislocation of the hip. This is because it is a spectrum of disorders, ranging from immaturity through instability to frank dislocation. The standard screening tests for this must be performed on day one after birth, when the sensitivity and specificity are greater than 60%. These are the famous Ortolani and Barlow tests. They are worth performing at the 6 week check as well, as occasionally they will be positive. Reduced range of abduction however is a more useful sign; I find that most children with a genuine loss of range do indeed have pathology such as DDH. A true limb length difference is probably as useful. Asymmetry of gait alone is not specific and requires a broad and detailed formal examination, including a neurological assessment. However, an experienced practitioner can usually tell the difference between the normal asymmetry of a toddler gait and something more important. There is on-going and difficult epidemiological research into just how useful clinical signs are in the diagnosis of DDH. I can confirm however that asymmetry of skin creases on its own is not a reason for referral or investigation. At present the gold standard for babies under 4 months is hip ultrasound, the timing of which does depend on the clinical findings, but also on the history; in other words the presence of “risk factors”. These have recently been defined by the National Screening Committee of the NHS.
Further reading: National Screening Committee website, https://www.gov.uk/government/groups/uk-national-screening-committee-uk-nsc.
6 What is the role of the GP in the management of a child with scoliosis?
Remember that mild curves in the spine are normal and quite common. My advice would be to suspect scoliosis in a child with waist, rib or shoulder asymmetry, and a child with an apparent leg length difference. It can be detected best on forward bending but this can lead to over diagnosis. Every child with suspected scoliosis should have a neurological examination, including midline skin lesions. Scoliosis is not usually painful, so pain raises the possibility of infection, inflammation or neoplasia. Opinions on the management of scoliosis can vary between centres and between spinal surgeons, but involve observation, bracing and surgery, often in that order. Central to management is whether or not the curve will get worse and by how much; this depends on the age of the child, the size of the curve and the underlying diagnosis. The likelihood of surgery is not easy to discuss without this information and an understanding of each factor. It is because of the possibility of progression of the curve that close follow-up is needed and why this should be done in the scoliosis clinic. It is worth noting though that progression is more likely to be rapid in children under 12. Some children are advised to wear a spinal brace. The number of hours prescribed will vary from child to child. In order to maximise compliance, the GP the practice nurse and the community physiotherapist must be aware of what the prescription is. The braces are usually managed by an orthotist and physiotherapist, sometimes via the school, so familiarity with who is managing the brace is important too. Rubbing, discomfort, non-compliance and concerns about rapid progression of the curve or neurological symptoms should be referred to this team. Reassurance however is a vital part of the management of this condition, which often causes a great deal of anxiety; children with painless scoliosis should be encouraged to participate normally and to take exercise.
7 How should we assess and manage intoeing?
In-toeing is usually only pathological if there is a neurological cause, the commonest of which of course is cerebral palsy, generally associated with tip-toeing as well. A neurological examination should therefore be performed. All babies have internal tibial and femoral torsion which corrects gradually after walking age at a variable rate. These are easily examined with the child prone. Look at the feet at the same time: the lateral border should be straight or at least go straight with a gentle push; if it doesn’t, the child should be referred. If internal femoral and/or tibial torsion persists, as it does occasionally, treatment is rarely needed. The child who trips over his own feet will eventually learn not to.The child who throws her feet out sideways in circumduction when running will often chose to run less. Rarely do these conditions cause more than an inconvenience and a lot of concern; sometimes however they are associated with joint pain from working at end of range, particularly the awkward combination of persistent internal femoral torsion and compensatory external tibial torsion.
8 Parents often attribute a child being clumsy or ‘tripping over his own feet’ to a variety of minor orthopaedic issues – such as intoeing, flat feet and so on. Are they correct – and are these symptoms ever a sign of anything more significant?
The child with tripping and clumsiness might have an orthopaedic condition, but apart from profound in-toeing, these are rarely the presenting complaints. The community paediatrician should be the first port of call if a specialist opinion is needed.
9 What problems are caused by joint hypermobility? How can GPs recognise it, and how should it be managed?
There is a spectrum of joint laxity or hypermobility, often familial or racial, and this can lead to some confusion when the child has musculoskeltal symptoms; often the diagnosis of a “hypermobility syndrome” is given to the child by a physiotherapist or rheumatologist. Some connective tissue disorders, notably Ehlers-Danlos and Larsen syndromes, are associated with joint instability and progressive degenerative change. Children are generally referred with these conditions by their hospital specialists, and most orthopaedic surgeons are happy to deal with the specifics, such as congenital dislocations of the hip or knee, recurrent dislocation of the shoulder or patella, but joint hypermobility per se and the so-called “hypermobility syndrome” are not seen as orthopaedic conditions.
10 How can common knee problems such as Osgood Schlatter’s and anterior knee pain be diagnosed confidently – and how are they best managed?
The assessment of anterior knee pain is one of careful history taking and physical examination. As with any limping child, infection has to be ruled out (see above). Knee pain in children often comes from the hip and sometimes the spine or thigh, so the hip spine and thigh must be examined too. Osgood Schlatter’s occurs in older children and young teenagers; it typically is a hangover pain, so the child does not stop the provocative activities because they are relatively pain-free; the child should point exactly to the tibial tuberosity, which should be swollen and tender; crucially the rest of the hip, knee spine and thigh examination should be normal. Treatment is symptomatic as it rarely persists beyond maturity and does not cause long-term damage. If on history and examination there is clearly a patello-femoral problem which is preferably bilateral and is activity-related but also worse with prolonged sitting (typically on the bus or in the cinema) it will almost always respond to physiotherapy. Focal signs such as local swelling, specific and reproducible tenderness, and/or an effusion warrant further investigation or referral.
11 What ‘red flags’ exist to point towards significant orthopaedic pathology in children?
If a child is in pain or unwell it can be difficult to home in on the cause, but a careful history often reveals how the condition evolved. Signs such as a limp, inability to bear weight, spinal or limb deformity, swelling, tenderness or pseudoparalysis all indicate that the pathology is likely to be orthopaedic. Needless to say, the possibilities of child abuse and non-accidental injury must be considered, particularly for children who present with an injury before walking age.